Diagnostic Tests That May Be Used in the Medical Assessment of Suspected Physical Abuse and Differential Diagnoses

Type of Injury or ConditionDiagnostic TestsComments
FracturesSkeletal survey: humeri, forearms, femurs, lower legs, hands, feet, skull, cervical spine, thorax (including oblique views61) and lumbar spine, pelvis621. Recommended for all children with fractures and children with any suspicious injuries under age 2
2. Repeat skeletal survey in 2 wk for high-risk cases63
3. Single whole-body films are unacceptable
BruisesTests for hematologic disorders: CBC count, platelets, prothrombin time, partial thromboplastin time, INR, bleeding time; additional testing (eg, factor levels) may be indicated after initial screening tests1. Recommended when bleeding disorder is a concern because of clinical presentation or family history
2. A DIC screen should be performed for patients with intracranial injury, because intraparenchymal damage can alter coagulation64
3. PFa-100: platelet function activity is preferable to bleeding time for establishing platelet function but is not widely available
Liver injuryLiver enzyme tests: aspartate aminotransferase and alanine aminotransferase1. May be helpful in diagnosing occult hepatic injury65
Pancreatic injury, pseudocystPancreatic enzymes: amylase and lipase
Urinary system/renal injuryUrinalysis
Intracranial and extracranial injuryMRI: head/neck1. Diffusion-weighted scan may surpass CT in characterizing extent of intercerebral edema66
2. May provide better dating of intracranial injuries than CT
3. More sensitive than CT for subtle intracranial injuries in patients with normal CT results and abnormal neurologic exams67
4. More sensitive than plain radiographs and CT for detecting cervical spine fractures/injury68
Intracranial and extracranial injuryCT scan: heada1. When used in conjunction with radiographs, may enhance detection of skull fractures
Intracranial injuryUrine: organic acids1. Screen for glutaric aciduria type 1
Intra-abdominal injuriesCT scan: abdomen1. IV contrast should be used and is preferable to PO62
Cardiac injuryCardiac enzymes: troponin and creatine kinase with muscle and brain subunits (CK-MB)
SkeletalRadionuclide bone scan1. Better for acute rib fractures and subtle, nondisplaced long-bone fractures62
Osteogenesis imperfectaSkin biopsy for fibroblast culture and/or venous blood for DNA analysis
Bone-mineralization disorders: ricketsCalcium, alkaline phosphatase, phosphorus, vitamin D, and parathyroid hormone
  • Tests should be ordered judiciously and in consultation with the appropriate genetics, hematology, radiology, and child abuse specialists. Careful consideration of the patient's history, age, and clinical findings should guide selection of the appropriate tests. CBC indicates complete blood cell; INR, international normalized ratio; DIC, disseminated intravascular coagulation; CT, computed tomography; IV, intravenous; PO, oral; CK-MB, creatine kinase MB band.

  • a CT scanning may provide clinically relevant information more expeditiously than MRI in some facilities.